Eligible Employees: All Full-Time United States Employees working in the United States scheduled to work at least 30 hours per week, excluding Employees enrolled in the Alternate Plan
Effective Date: November 1, 2024
Plan type PPO
Dental PPO Network Sun Life Dental NetworkSM
In-Network Reimbursement Sun Life Dental NetworkSM
Out-of-Network Reimbursement
90th Percentile of the Usual and Customary Charge
Orthodontic coverage (Type IV) Not included
Dependent Coverage
Children Children to age 26
Open enrollment at Issue Yes
Employee coverage contributions
Dependent coverage contributions
Employee pays for a portion or all of the cost of Employee coverage
Employee pays for a portion or all of the cost of Dependent coverage
The listed coinsurance percentages shown below represent the portion of Sun Life’s allowable charge for which the plan will be responsible. Network providers agree to accept the network's allowable charge for covered services as payment in full. If covered employees or their eligible dependents receive services from a non-network provider, Sun Life will apply the coinsurance percentages shown below to 90th Percentile of the usual and customary charge for covered services and they will be responsible for the difference up to the provider’s charge.
Group insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) under Policy Form Series 15-GP-01 and 16DEN-C-01.
Proposal for Houston Bark Park and Daycare, Inc.
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April 5, 2024 Case ID: 2402142
Plan Year Deductible
Type I Preventive Services
Type II Basic Services
Type III Major Services
Type IV Ortho Services
$50 individual / $150 family
Not applicable
$50 individual / $150 family
Not applicable
Deductible values are combined between In-Network and Out-of-Network.
Coinsurance
Benefit Waiting Periods
• A Late Entrant Benefit Waiting Period of 12 months for Type III Major Services will apply to employees who enroll in this dental plan more than 31 days after becoming eligible.
Plan Year Maximum Benefit
Types I, II and III (Preventive, Basic and Major) Services
This plan includes Preventive Max Waiver®, which makes regular dental checkups easy by not counting Type I Preventive expenses toward the annual plan maximum. This leaves more coverage for employees and their covered dependents when they need it most, encouraging employees to maintain good oral health with routine care.
Group insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) under Policy Form Series 15-GP-01 and 16DEN-C-01.
Proposal for Houston Bark Park and Daycare, Inc.
Page 8 of 24
April 5, 2024 Case ID: 2402142
Covered expenses
Type I Preventive covered dental expenses
Oral Evaluations
Dental Prophylaxis (Cleanings)
Fluoride Treatments
Sealants
Coverage limitations
2 in any benefit year
2 time per benefit year - is limited to 2 of these services in any benefit year
Covered Persons under age 14 1 in any 6 consecutive months
Covered Persons under age 14
Once per tooth per 36 consecutive months on permanent first and second molars
Full Mouth X-Rays 1 in 60 consecutive months
Bite-Wing X-Rays 1 in 12 consecutive months
Intraoral X-Rays
Type II Basic covered dental expenses
Palliative Treatment
Periodontal Maintenance
Amalgam Restorations
Composite and Silicate Restorations
Space Maintainers
Periodontics (Non-Surgical):
Scaling and Root Planing
Surgical Periodontics
Type III Major covered dental expenses
Inlays and Onlays
Crowns
4 Films in any 12 month period
Coverage limitations
Paid as a separate benefit only if no treatment, except x-rays, was rendered during the visit
Periodontal Maintenance following active Periodontal Therapy2 per benefit year
Once per tooth surface in any 24 consecutive months
Once per tooth surface in any 24 consecutive months and excluding posterior teeth
Covered Persons under age 19
Once per tooth in any 3 year period
Once per 24 consecutive months per area of the mouth
Once per 36 consecutive months per area of the mouth
Coverage limitations
Covered if tooth cannot be restored by fillings
Once per tooth in any 10 years period
Covered if tooth cannot be restored by filling or other means
Once per tooth in any 10 years period
Crown Buildup Once per 10 years
Full or Partial Dentures Once in any 10 years
Fixed Bridges Once in any 10 years
Endodontics: Root Canal Therapy
Oral Surgery:
Surgical Extraction of Erupted and Impacted Teeth
General Anesthesia
Root Canal Therapy is limited to 1 time per tooth in any consecutive 24 months period
Multiple surgical services on 1 area of the mouth will be based on the most inclusive procedure
Benefits payable as a separate expense only when required for the surgical extraction of an impacted tooth
Group insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) under Policy Form Series 15-GP-01 and 16DEN-C-01.
Proposal for Houston Bark Park and Daycare, Inc.
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April 5, 2024 Case ID: 2402142
Dental rates and premium
For illustration purposes, the total employees shown for each plan is based on data provided to us. Actual employee count will vary at final enrollment.
Sequence Number: 2
Included in this plan:
· A Flat 15% broker commission
· 12-month rate guarantee from the Effective Date
· Rates assume 57 eligible employees, with 11 participating or 19.3% participation. Upon sale, quoted rates and benefits may be adjusted based on achieved participation levels
· Sun Life reserves the right to adjust rates if final participation is more than 10% different than the participation shown here
· Rates assume employees in this class have a choice between this plan and our Prepaid/DHMO plan.
Group insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) under Policy Form Series 15-GP-01 and 16DEN-C-01.
Proposal for Houston Bark Park and Daycare, Inc.
Page 10 of 24 April 5, 2024 Case ID: 2402142
Assumptions
· Prior dental plan certificates are required.
· Rates available with a minimum participation of 20% of eligible employees (10 life minimum).
· Dual Choice must have 20 eligible employees and 10 enrolled lives (5 in each plan).
· Rates are based on the assumption that dental has been in force for 24+ months. We reserve the right to re-rate if coverage has been in force for less than 24 months.
· Assumes direct employer-employee relationship.
· Sun Life is assumed to be the sole provider of dental insurance to the employer named in this proposal.
· Notification of any employer-completed merger or acquisition.
· Standard Sun Life policy language, as filed in the policyholder’s situs state, is offered. No special language or state filings are included unless approved in advance and policy provisions are subject to state requirements and availability.
· An employee must be Actively at Work on his/her Effective Date for coverage to become effective. If an employee is not Actively at Work on his or her Effective Date, coverage will not become effective until the employee is again Actively at Work. Continuity of coverage may apply for takeover plans.
· Common ownership of the business units.
· If post-enrollment review shows that the group did not meet all of the underwriting requirements, we reserve the right to re-rate retroactive to the Effective Date or terminate the contract.
This dental plan does not provide coverage for pediatric oral health services that satisfies the requirements for “minimum essential coverage” as defined by the Patient Protection and Affordable Care Act. (“PPACA”).
Group insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) under Policy Form Series 15-GP-01 and 16DEN-C-01.
Proposal for Houston Bark Park and Daycare, Inc.
Page 11 of 24 April 5, 2024 Case ID: 2402142
Group Prepaid Dental
This plan is for employees located in Texas. All Eligible Employees
Plan Design and Fees Plan design summary
Dental Plan Overview
Eligible Employees All Full-Time United States Employees working in the United States who are scheduled to work a minimum of 30 hours per week
Effective
1, 2024
Dental Fees
* Cost Includes the Specialty Benefit Sequence Number: 4
Included in this plan:
· Sun Life’s Dental Flat Percent broker commission
· 12 month fee guarantee from the Effective Date
· Minimum participation requirements of 5 enrolled employees per state
Proposal for Houston Bark Park and Daycare, Inc.
PLUS PLAN
Sample Copayment Schedule
1. Plan Dentist Services
The dental services listed in the following schedule are covered only when provided by the Member's selected Plan Dentist. The Member will be responsible for paying the amount listed in the "Member Copayment" column plus any applicable lab fees at the time the service is received, or in accordance with the selected Plan Dentist's billing procedures. Dental services that do not appear on this list are not covered by the Plan. The Plan Dentist is permitted to charge the Member for any missed appointments if the Member fails to give at least 24 hours notice. The charge may not exceed $20.00.
*Services marked with a single asterisk (*) below also require separate payment of laboratory charges. The laboratory charges must be paid to the Plan Dentist in addition to any applicable copayment for the service.
Payment for each service of a Non-Plan Dentist (at that dentist's normal retail charge) is the responsibility of the Member, except for Plan Benefits for covered dental Emergency Services.
2. Plan Specialty Dentist Services
Should the Member require dental services that his or her selected Plan Dentist is unable to provide, he or she may obtain those services from a Plan Specialty Dentist at a reduced rate. No referral is needed from the selected Plan Dentist in order for the Member to obtain services from a Plan Specialty Dentist.
There is no applicable copayment schedule for Plan Specialty Dentist services. Instead, the following reductions in that Plan Specialty Dentist's normal retail charges apply to all services received from a Plan Specialty Dentist. A 15% reduction applies if the dentist's specialty is endodontics. A 25% reduction applies if the dentist has any other type of specialty, including but not limited to orthodontics. The Member is responsible for paying the entire reduced charge at the time the service is received, or in accordance with the Plan Specialty Dentist's billing procedures.
Payment for each service of a Non-Plan Specialty Dentist (at that specialty dentist's normal retail charge) is the responsibility of the Member, except for Plan Benefits for covered dental Emergency Services.
(once in any 6 calendar months) (may only be obtained once in any 6 calendar months, except for medically necessary more frequent prophylaxis as determined by Member's Plan Dentist)...........................................................................................
D0150 Comprehensive oral evaluation - new or established patient (once in any 6 calendar months) (may only be obtained once in any 6 calendar months, except for medically necessary more frequent prophylaxis as determined by Member's Plan Dentist)
D0170
D0210 Intraoral - comprehensive series of radiographic images (once in any 3 calendar years) No Charge
D0220 Intraoral-periapical first radiographic image
D0230 Intraoral-periapical each additional radiographic image
D0240 Intraoral-occlusal radiographic image
D0250 Extraoral-2D projection radiographic image created using a stationary radiation source, and detector
D4260
This is a sample Member Copayment Schedule only. It is not an Evidence of Coverage. Please see the Group Dental Service Agreement, Evidence of Coverage, and Copayment Schedule, which determine all rights, benefits, and applicable limitations and exclusions.
Listed copayments apply only to Plan Dentists who perform the corresponding listed services. The Plan Dentist selected by the Member may not perform all listed services. Availability of Plan Dentists is subject to change.
***Service does not have an American Dental Association Current Dental Terminology code or descriptor.
Assumptions
This dental plan does not provide coverage for pediatric oral health services that satisfies the requirements for “minimum essential coverage” as defined by the Patient Protection and Affordable Care Act. (“PPACA”).
Limitations & Exclusions Termination
Pre-existing Conditions
Limitations and exclusions apply with respect to the Member’s oral conditions without regard to whether or not such conditions existed before the effective date of the Member’s enrollment.
Limitations and Exclusions
Plan Benefits are not available for:
1. Any services not specifically described in the Copayment Schedule (including but not limited to any hospital or outpatient care facility cost associated with any dental service). However, the reference to “hospital or outpatient care facility” does not include a dentist’s office, dental clinic, or other comparable facility when the services described in the Copayment Schedule qualify as Emergency Services as defined in the Evidence of Coverage.
2. Any part of any dental service for which (a) a charge is incurred before the effective date of Member’s enrollment for Plan Benefits (except as provided in the ORTHODONTIA SERVICES Section of the Copayment Schedule) or (b) after Member’s enrollment for Plan Benefits ends. This exclusion means only that payment of the incurred charge, at the provider’s entire normal retail cost for that part of that service, remains the Member’s responsibility after the Member enrolls for Plan Benefits.
3. Services provided by Non-Plan Providers unless (a) for services of Non-Plan Specialty Dentists as specifically provided in the SPECIALTY DENTIST SERVICES section of the Copayment Schedule or (b) for Emergency Services as specifically provided in the EMERGENCY PROCEDURES Article of the Evidence of Coverage.
4. Replacement of bridgework, dentures or other fixed or removable appliances unless (a) at least five years have elapsed since such appliance was provided as a Plan Benefit, or (b) during that five-year period, appliance becomes unusable and cannot be made usable due to the Member’s illness or an accident involving damage to the appliance while it is in use.
5. Replacement of dentures or other removable appliances due to (a) damage while not in use or (b) loss or theft.
6. Oral reconstruction using fixed bridgework or other fixed appliances if the overall treatment plan to achieve complete oral reconstruction involves the replacement of six or more teeth (whether those teeth are missing before treatment begins or are extracted as part of the overall treatment plan).
7. Implants or any related implant appliances, or surgery for the insertion of implants or any related implant appliances, whether fixed or removable.
8. Surgical removal of implants or implant appliances, or any surgical or non-surgical services to adjust, repair, replace, or treat any problem related to an existing implant or implant appliance, whether fixed or removable.
9. Restorations or splints used to increase vertical dimension, restore occlusion, or replace or stabilize tooth structure lost by attrition.
10. Orthodontic treatment involving therapy for myofunctional problems, TMJ (temporomandibular joint) dysfunctions, micrognathia, macroglossia, cleft palate or other growth and developmental abnormalities.
11. Orthodontic treatment associated with orthognathic surgery, whether the treatment precedes or follows the surgery.
12. Extractions of third molars (wisdom teeth) that are not symptomatic, whether or not the extractions follow the completion of orthodontic treatment. Examples of symptomatic conditions include decay, odontogenic cysts, chronic pericoronitis and infection.
13. Treatment of malignancies, neoplasms or cysts, including but not limited to biopsies.
Orthodontic Extractions
Extractions by a Plan Provider for solely orthodontic purposes are not subject to the fixed Copayments shown for extractions in the Copayment Schedule. Instead, such extractions are subject to charges reflecting a 25% reduction from that Plan Provider's normal retail charges for such extractions.
Renewability
After the initial Plan Year, each Plan Year of the Group Dental Service Agreement (Agreement) shall have a twelve-month term. The Agreement automatically renews each Plan Anniversary unless cancelled or otherwise terminated.
Termination
The Agreement may be terminated by United Dental Care of Texas, Inc. for failure to pay proper monthly Prepayment Fees or (if applicable) the proper monthly Administration Fee, fraud or misrepresentation of fact in obtaining coverage under the Agreement, or material breach of any provision of the Agreement.
Proposal for Houston Bark Park and Daycare, Inc.
Page 19 of 24 GDOT-6209
April 5, 2024 Case ID: 2402142 rev. 06090615
Cancellation
The Agreement may be cancelled at the Plan Anniversary or after the initial Plan Year, without cause, upon prior written notice by United Dental Care of Texas, Inc. or Employer as stated in Agreement.
Proposal for Houston Bark Park and Daycare, Inc.
Page 20 of 24
April 5, 2024
Case ID: 2402142 rev. 06090615
Group Vision
All Eligible Employees Plan design and rates
Plan 3 design summary
Eligible Employees
All Full-Time United States Employees working in the United States Who Are Scheduled To Work A Minimum Of 30 Hours Per Week
Effective Date November 1, 2024
Plan Type Plan 3
Locating a VSP doctor A listing is available at vsp.com or by calling 1.800.877.7195
Out-of-Network Providers Members will receive a lesser benefit and should contact VSP at 1.800.877.7195 for more details.
Dependent Coverage Children Children to age 26
Annual Enrollment Period This plan includes an annual enrollment period, which provides an opportunity for late applicants to join the plan and allows for benefit changes.
Employee Coverage Contributions Employee pays for a portion or all of the cost of Employee coverage
Dependent Coverage Contributions
Employee pays for a portion or all of the cost of Dependent coverage
Group Vision coverage is underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) under Policy Form Series 15-GP-01.
Proposal for Houston Bark Park and Daycare, Inc.
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April 5, 2024
Case ID: 2402142
Plan 3 Covered Expenses
- Full Service
Laser Vision Correction Discount
Lenses
Single Lined
Bifocal Lined
Trifocal
Lenticular
Necessary Contacts
Lens Enhancements
Once per eye per lifetime · Average 15% off the regular price or 5% off the promotional price.
· Discounts only available from contracted facilities.
1 per 12 months $25 (lenses and frame) Up to $30 Up to $50 Up to $60 Up to $100 Up to $210
Standard progressive Premium progressive Custom progressive No cost
$95 - $105 copay
$150 - $175 copay
Average savings of 20-25% on other lens enhancements
Frames
Includes a wide selection of frames at Walmart®
Elective Contact Lenses
Contact lenses are in place of lenses and frame.
Additional Glasses and Sunglasses Discount
Coverage with Retail Providers
1 per 24 months · $130 for the frame of your choice and 20% off the amount over your allowance
· $70 allowance at Costco®* Up to $70
1 per 12 months · Up to $60 / 15% savings for your contact lens exam (fitting and evaluation)
· $130 for contact lenses Up to $105
20% off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your exam. Or get 20% off from any VSP doctor within 12 months of your last exam.
*Coverage with retail providers may be different. Check with Costco® and Walmart® for VSP member pricing. The Costco allowance is equivalent to the allowance at preferred providers and other retail providers.
Group Vision coverage is underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) under Policy Form Series 15-GP-01.
Proposal for Houston Bark Park and Daycare, Inc.
Page 22 of 24
April 5, 2024
Case ID: 2402142
Vision Rates and Premium
Sequence Number: 6
For illustration purposes, the total employee shown for each plan is based on data provided to us. Actual employee will vary at final enrollment.
Rates assume 57 eligible employees, with 15 participating or 26.3% participation. Upon sale, quoted rates and benefits may be adjusted based on achieved participation levels.
Sun Life reserves the right to adjust rates if final participation is more than 10% different from the participation provided at quote.
Included in this Plan:
· A flat 10% broker commission
· 12-month rate guarantee from the Effective Date
· The rates quoted are based on the information provided to us at the time of proposal and reflect the risk presented and benefits requested at that time. Any change in our risk or any change in the benefits requested may result in a change of premium rates, a change in the plan offered, or a withdrawal of the proposal.
Group Vision coverage is underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) under Policy Form Series 15-GP-01.
Proposal for Houston Bark Park and Daycare, Inc.
Page 23 of 24 April 5, 2024
Case ID: 2402142
Assumptions
· A minimum of 20% participation or 2 employees is required at point of sale. If the enrollment of this group drops below 2 employees this proposal is not valid.
· This fully insured plan will replace any VSP discount plan currently offered by Sun Life.
· Claim forms are not required for in-network vision providers.
· Assumes direct employer-employee relationship.
· If Experience is provided, any plan changes within the experience period must be disclosed at the time of quoting.
· Sun Life is assumed to be the sole provider of vision insurance to the employer named in this proposal.
· Notification of any employer-completed merger or acquisition.
· Standard Sun Life policy language, as filed in the policyholder’s situs state, is offered. No special language or state filings are included unless approved in advance and policy provisions are subject to state requirements and availability.
· An employee must be Actively at Work on his/her Effective Date for coverage to become effective. If an employee is not Actively at Work on his or her Effective Date, coverage will not become effective until the employee is again Actively at Work. Continuity of coverage may apply for takeover plans.
· Common ownership of the business units.
· Sun Life requires a final census, which includes participation information for contributory/voluntary benefits, before the point of sale and reserves the right to re-rate the proposal upon verification of dates of birth, genders, salaries, individual benefit elections, and occupations.
· If post-enrollment review shows that the group did not meet all of the underwriting requirements, we reserve the right to re-rate retroactive to the Effective Date or terminate the contract.
· The rates quoted are based on the information provided to us at the time of proposal and reflect the risk presented and benefits requested at that time. Any change in our risk or any change in the benefits requested may result in a change of premium rates, a change in the plan offered, or a withdrawal of the proposal.
This vision plan does not provide coverage for pediatric vision health services that satisfies the requirements for “minimum essential coverage” as defined by the Patient Protection and Affordable Care Act. (“PPACA”).
Group Vision coverage is underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) under Policy Form Series 15-GP-01.
Proposal for Houston Bark Park and Daycare, Inc. Page 24 of 24
